Master of Public Health - MPH / Access to appropriate health care service during childbirth is a great challenge to many women in Africa and Namibia is no exception. More than 70% of women in Otjozondjupa region experienced some form of delay during childbirth, and while maternal mortality continued to rise over the years in Namibia it is currently at about 265/100 000, which is too high for a middle-income country. Hence, this study aimed to get a deeper understanding of the perceptions of women who experienced any of the three delays in accessing appropriate health care during childbirth in Otjiwarongo hospital.

OBJECTIVES: We conducted a mixed methods study of delayed access to emergency obstetrical care among preeclamptic and non-preeclamptic women in Port au Prince, Haiti, grounded in the Three Delays model of Thaddeus and Maine. The primary objectives were to identify factors affecting delays in accessing care and clinical consequences of delays. METHODS: 524 surveys were administered to women admitted to the Médecins Sans Frontières (MSF) obstetric emergency hospital. Survey questions addressed demographic, clinical, and behavioral risk factors; first (at home), second (transport) and third (health facility) delays; and clinical outcomes for women and infants. Bivariate statistics were used to assess relationships between preeclampsia status and delay, and between risk factors and delay. Twenty-six survey participants with lengthy delays (> 6 hours) were chosen for interviews, which elicited details about delays women experienced. Data were analyzed using a grounded theory approach. RESULTS: We found long delays to accessing care for preeclamptic women (median 5.0 hours, IQR 10.5, vs. 4.0 hours, IQR 5.0, for non-preeclamptic women, p<0.01), primarily due to delays at home before leaving for the hospital (median 2.6 hours, IQR 10.6). No demographic, clinical, or behavioral factors were related to access to care. Women's health prior to pregnancy was not associated with delays, with the exception of preeclamptic women who had previously seen a doctor, who had significantly longer delays than women who had not previously seen a doctor (22.8 hours versus 11.2 hours, p=0.02). Long delays for both preeclamptic and non-preeclamptic women were not associated with poorer clinical outcomes. Although the MSF hospital is free of charge, financial barriers at other hospitals limited access to emergency obstetric care for many women, who commonly experienced non-evidence-based care, including inappropriate education from antenatal care providers when diagnosed with hypertension or preeclampsia. CONCLUSIONS: Pregnant women with preeclampsia in Port au Prince reported significant delays in accessing emergency obstetric care. Many delays stemmed from poor quality antenatal care services, which fail to screen, treat, or educate women appropriately. Improvements should be made in education and supervision for antenatal care providers, and in accessibility of emergency services at public hospitals in Port au Prince.

After the 1994 genocide and collapse of the health system, Rwanda initiated major social and health reforms in order to reduce child mortality and health inequities in accordance with the Millennium Development Goals. The aim of this thesis was to assess trends in under-five mortality (U5M) and equity in child survival, to study social barriers for improved perinatal and neonatal survival, and to evaluate Helping Babies Breathe (HBB), a newborn resuscitation program. In paper I we analysed trends and social inequities in child mortality 1990−2010, using data from national Demographic and Health Surveys conducted in 2000, 2005, and 2010. The following papers were based on hospital studies in the capital of Rwanda. In paper II we explored social inequities in perinatal mortality. Using a perinatal audit approach, paper III assessed factors related to the three delays, which preceded perinatal deaths, and estimates were made of potentially avoidable deaths. Paper IV evaluated knowledge and skills gained and retained by health workers after training in HBB. Under-five mortality declined from the peak of 238 deaths per 1000 live births (95% CI 226 to 251) in 1994 to 65 deaths per 1000 live births (95% CI 61 to 70) in 2010 and concurred with decreased social gaps in child and neonatal survival between rural and urban areas and household wealth groups. Children born to women with no education still had significantly higher under-five mortality. Neonatal mortality also decreased but at a slower rate as compared to infant and U5M. Maternal rural residence or having no health insurance were linked to increased risk of perinatal death. Neither maternal education nor household wealth was associated with perinatal mortality risks. Lack of recognition of pregnancy danger signs and intrapartum-related suboptimal care were major contributors to perinatal deaths, whereof one half was estimated to be potentially avoidable. Knowledge significantly improved after training in HBB. This knowledge was sustained for at least 3 months following training whereas practical skills had declined. These results highlight the need for strengthening coverage of lifesaving interventions giving priority to underserved groups for improved child survival at community as well as at hospital levels.